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Winds of Change Mental Health Center, Missoula, MT

January 15 & 16

2015

A report of the Board of Visitors site inspection of services for adults, provided by Winds of Change Mental Health Center.

Mental Disabilities Board of Visitors

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Overview Mental Health Facility Inspected

Winds of Change Mental Health Center Kay Jennings, Director

Authority for Inspection

Montana Code Annotated, 53-21-104 Purpose of the Inspection

To inspect the outpatient mental health/psychiatric services for adults at the Winds of Change Mental Health Center

To inspect the group homes J’s Place, La Casa and Casa Dos.

To inspect the services provided at the Recovery Mall

To assess the degree to which the services provided by Winds of Change are consistent with professional standards and state statutory requirements, and incorporate Board of Visitor Standards for mental health services.

To look for utilization of evidence-based programs and practices and implementation of recovery-based programs.

To make recommendations to Winds of Change for enhancing and/or improving mental health services.

To report to the Governor and the Montana Legislature regarding the services provided at Winds of Change.

Board of Visitors Site Inspection Team Miriam Hertz, Board Member; Susan Bodurtha, PMHCNS, Consultant; Craig Fitch, Legal Counsel; LuWaana Johnson; Dennis Nyland, Mental Health Ombudsman; Janette Reget, LCSW, Executive Director, Board of Visitors Inspection Process

Interviews with Winds of Change Staff

Informal discussions with residents

Observation of treatment activities

Inspection of physical campus and buildings

Review of written descriptions of treatment programs

Review of treatment records

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Summary Winds of Change Mental Health Center provides a full array of services for adults in Missoula, Montana. The program provides crisis response services for clients through the provision of a crisis telephone line at J’s Place, supported living options through the J’s Place, La Casa, and Casa Dos Group Homes, outpatient services, including case management, Community Based Psychiatric and Rehabilitation Services, (R & S), Recovery Mall, individual and group therapy, and psychiatric services through Aleph, PC, for adults with mental health needs. Their emphasis is on Recovery, and Winds of Change staff believes treatment is the means to achieve Recovery. They believe that clients should be in control of their own lives and Winds of Change is there to help clients make choices that will help them move towards Recovery. In this way, the client feels more empowered in their own care and lives. The Mental Disabilities Board of Visitors (BOV) site inspection team was greatly impressed by the overall quality of programs and services provided to clients at Winds of Change. Staff is enthusiastic, positive, proactive, and caring. They are well-trained, with an emphasis on Recovery. Staff seems to enjoy their jobs and is dedicated to delivering quality services to the clients.

Standards for Site Inspections of Mental Health Services Organizational Planning and Quality Improvement Winds of Change has a strategic plan that is reviewed at three month and six month intervals. The strategic planning process incorporates all of the information gathered through the quality assurance plan, which includes client satisfaction survey data. The strategic plan was not available for review. Winds of Change provided to the Board of Visitors the agency’s Mission Statement and goals, as well as proposed program changes for 2014 that were specific and measurable. These were based on client input and satisfaction surveys. Recommendations for Review by the leadership team on March 20, 2013 identified several client suggestions that have been or will be implemented at Winds of Change. Plans include renovation of J’s Place and possibly building a new residential group home. Each program manager within Winds of Change is responsible for gathering quality assurance information within their own program. The Vice President of Operations of the organization is responsible for maintaining the data and leading the regularly scheduled quality assurance meetings. As part of the quality assurance process, management looks for trends in staff and client comments, and makes recommendations and changes based on those trends. Quality assurance managers meet monthly, and meet quarterly with clients for direct input regarding service delivery and treatment. Client satisfaction surveys are sent out on a regular basis and incorporated into the quality improvement process.

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Winds of Change seeks input from clients in many ways:

Safety meetings held monthly or at least every other month. Emphasis is on ways to keep clients safe. For example, in January, riding the city bus became free. Many Winds of change clients from outside Missoula were concerned they would lose their way. The solution was to give each client an ID card with the group home address and phone number on it to help clients tell others where they live.

Listening Lunch is held quarterly. Clients talk to staff about areas of concern. During this site inspection, clients provided to staff ideas about how to respond when the client is in crisis.

Resident Council is a meeting run by clients to address clients’ concerns and to suggest ideas for improvements in client services; occasionally staff runs it because no client will volunteer. Resident council requested to have more R & S staff work in the evenings and on weekends. Extra staff was hired. Other requests included adding a stair stepper to the Wellness Center, addressing client hygiene, peer training, and learning how to ride the bus (a group was developed to teach clients how to ride the bus, find their way around town, and feel comfortable about it).

Client satisfaction surveys indicated the majority of clients at Winds of Change (77.75%) are extremely satisfied with services provided by Winds of Change; clients interviewed stated that they felt hopeful, supported, and valued. Clients say there is less emphasis on symptoms and more emphasis on recovery. They reported they were pleased with services provided by Case Managers and Community Based Psychiatric Rehabilitation (R & S) staff.

Rights, Responsibilities and Safety Most staff is aware of and provides individuals with the information/forms regarding their rights and responsibilities at the facility. This appears to be the process when a client first enters the services of Winds of Change. Upon entering services, each client is given a Welcoming Packet that includes information about rights, responsibilities, and safety. The client signs a form indicating s/he is aware of clients’ rights. The case manager reviews clients’ rights with the client, who re-signs it on a yearly basis. It should be noted in the hallway outside of the Recovery Mall, there is a large display with a large number of brochures/information for advocacy services, as well as many other services. Staff has a good understanding of the grievance policies and how to respond to allegations of abuse/neglect. Interviewed staff is familiar with the different advocacy programs in their service area and other advocacy services/groups statewide. When a client enters the services of Winds of Change, they are given advocacy information verbally, along with other forms and information (individual rights/grievance process, etc.). Contact information for advocacy services (Board of Visitors, Mental Health Ombudsman, and Disability Rights Montana) is posted at Winds of

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Change, and at J’s Place, but could be more prominent. It was hard to locate on the bulletin board. Contact information needs to be posted at La Casa and Casa Dos. Winds of Change has a clear grievance procedure. Grievances submitted to R & S staff or case managers are sent to the immediate supervisor who attempts to resolve it. If the client is not satisfied, Stacey Wheeler will review, and if the client is still not satisfied an appeal is submitted to Kay Jennings. Winds of Change’s abuse and neglect policies and procedures are clearly written and directly incorporate the requirements of 53-21-107 MCA. Staff interviewed was able to accurately identify whichever aspects of the reporting policy that they would be responsible for. Staff stated once an allegation is brought forward, they would contact their supervisor immediately and would start the process of filling out the appropriate paperwork regarding the incident. Stacey Wheeler deals with all alleged abuse/neglect investigations. Every staff member is trained in CPI techniques for de-escalation of clients. The staff learns safe holds but emphasis is put on de-escalating an upset client. Staff will never put hands on clients. When a client has a “melt-down”, staff is taught to step in very respectfully and ask what is wrong, using probing questions. Staff does not step in alone, but at the same time they do not “bombard” the client with staff. Individuals do have access to a staff of their own gender when appropriate or requested.

Individual and Family Members/Guardian Participation Winds of Change is definitely very proactive with individual recovery and many of their programs/activities show that. When asked about having family members/guardians participation with the client’s treatment and recovery, it was stated over and over that Winds of Change’s focus is on the independence of clients working on their recovery. Staff stated that clients generally do not want, or have no need for, family involvement and that this along with HIPAA privacy regulations results in little or no contact between staff and family members. One staff person thought that family members may be utilizing support groups and programs offered by the Missoula chapter of NAMI. At the same time, staff informed the Board of Visitors that the decision about family participation in treatment is up to the client, as an adult, to choose. Additionally, several family members may not want to be involved in the clients’ treatment. Nevertheless, the Board of Visitors encourages continued efforts to involve families in the clients’ recovery. Positive family involvement is generally a support to consumers of any type of service and is also helpful to consumers’ family dynamic. A support system is an important component of the recovery process. Currently, there are 28 residents staying in the group homes. Eight have family members who are invested in their life and treatment.

Cultural Effectiveness Winds of Change utilizes staff trainings offered online by the company Relias Learning. One of Relias Learning’s training modules is on cultural sensitivity. Program administrator Stacey Wheeler stated that annually, staff takes Relias Training to address culture in treatment. In

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2014, it was “Cultural Issues in Mental Health”, and in 2015 it is “A Culture Centered Approach to Recovery.” She stated that Mr. Tom Camel did two trainings in the past, and Mr. Brian Barnett also did two trainings. The last “live” training was about two years ago. These trainings emphasized culture in treatment and using culture as strength. Cultural issues are addressed in the Clinical Assessment. Resources are discussed during case reviews and staffings. Sensitivity training specifically regarding American Indian cultures, which is the largest ethnic minority served by Winds of Change, could be delivered by Medicine Wheel, a company that became known to Winds of Change J’s Place case manager Abigail Higgins when she was a student participant in Native American activities at The University of Montana (UM-Missoula), or perhaps could be provided by Marilyn Zimmerman, who is on the UM faculty. The University of Montana, which has strong programs in Native American Studies and Social Work, can be used as a source for American Indian cultural sensitivity training. Sensitivity training regarding military service members likely should include training on posttraumatic stress disorder (PTSD), which is a DSM-V diagnosis that is found disproportionately among military veterans and also found co-occurring with other DSM diagnoses.

Staff Competence, Training, Supervision, and Relationships with Clients Winds of Change is focused on giving clients basic holistic care. At the time of this site inspection, it appeared that record keeping was incomplete regarding ongoing assessment and symptom management from a psychiatric prescriber’s perspective in the clinical file. Further information provided after the site inspection stated that Winds of Change was very recently surveyed for licensure, and made corrections to clients’ charts based on that survey. Community Based Rehabilitation and Support staff (R & S) are required to have a high school degree. Winds of Change prefers to hire staff with past experience working with adults with SDMI. Case managers are required to have a BA degree although it does not have to be specifically in social work. Case managers’ responsibilities include assessing barriers to independent living, addressing communication skills, identifying symptoms and assisting in developing management skills and providing immediate crisis management. Therapists are required to have a Master’s degree. Continuity of care is dependent on providers and case managers being readily available to clients and each other. Winds of Change uses computer training through Relias Learning, with over 400 mental health topics available. Supervisors are encouraged to get training outside the agency as well as utilizing Relias training. All staff is required to complete an in-service and/or a Relias module monthly. Annual training for group home staff include blood borne pathogens, confidentiality and HIPPA, case management for paraprofessionals, handling food safety, essential documentation for

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paraprofessionals, motivational interviewing, serious mental illness for paraprofessionals, safe patient care, preventing medication errors and overview of psychopharmacology. 2014 training for group home staff included boundaries, dual relationships for paraprofessionals and cultural diversity. 2015 training will include understanding borderline personality disorder, co-occurring disorders and cultural diversity. Therapists focus on enhancing their knowledge base around motivational interviewing, solution based therapies, interpersonal/bio-rhythms (bipolar), Dialectical Behavior Training, narrative and schema therapy. Aleph staff educates Winds of Change staff on health topics including diet and exercise. Upper management is required to obtain 20 hours of education per year. It appears that Winds of Change has a good orientation training program, as well as ongoing training to give staff the optimum chance to have the knowledge and competence to do their job. Staff spoke highly of how well their orientation training went when they started at Winds of Change. They stated they had CPI training, Relias Training, and access to training materials/videos focusing on mental illnesses. They also stated they receive ongoing training, which includes monthly trainings, and annual trainings. A daily morning meeting for all staff, referred to as “Stand Up” includes various mindfulness practices. Staff stated after they start working at Winds of Change, they use “shadowing”, which allows them to work alongside more experienced staff to learn their duties/responsibilities. Supervision for case management focuses on boundaries, self-care, time management/ productivity, teamwork and mindfulness. Currently, staff is actively encouraged to improve organization around essential tasks and possibly decrease hours in order to take better care of self. Individual supervision occurs weekly for new case managers. 1:1 supervision occurs monthly for seasoned case managers. Case management meetings occur every 2 weeks as continuing supervision. Interviewed staff stated they felt immediate supervisors were readily available, were competent, and knowledgeable about the clients served. Staff appears to be courteous, attentive and positive in their interactions with clients. During a presentation by peers to staff, it is abundantly clear that clients were grateful for staff support and guidance. They acknowledged that staff attempted to address concerns in a positive manner and are willing to respect each client’s uniqueness. Interviewed staff seemed enthusiastic and committed to providing services to the clients. Three case managers who were interviewed stated, “I feel like I’m making a difference.” “I’m very busy.” Clients who were interviewed expressed appreciation for their case managers and other staff. Interviewed clients stated instead of addressing illness and symptoms, Winds of Change addresses hope, recovery, and validation.

Treatment and Support Upon admission, an individualized treatment plan is completed within 10 days, and is reviewed every 90 days. Clients, along with their case managers, actively develop and implement the treatment plans. Treatment plans address linkage to services such as Office of Public

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Assistance, housing, services in community, therapy, and benefits, wellness, and other recovery-based goals. For the most part, family members/guardians do not participate in treatment planning. Nurse practitioners are available from Aleph and perform physicals for all group home residents. Lab work ruling out a number of common physical conditions is ordered for every client accepting services at Winds of Change. If the client has a primary care provider in the community, lab results will be sent if a current release is in the chart. The community primary care physician can make a decision to treat underlying conditions or allow the nurse practitioner at Aleph to follow. Winds of Change assists clients to obtain necessary dental care. Winds of Change trains staff regarding trauma through formal and informal training. Therapists are well versed regarding trauma therapy but do not utilize EMDR or specialized trauma therapies. Dialectical Behavior Therapy groups are offered. Therapists have referred clients to community therapists specializing in complex trauma. There is not a specific debriefing protocol for traumatic events involving staff and clients. In December, 2014, an Introduction to Trauma Informed Care was provided through Relias Learning; this appears to be the only Trauma Informed Care training provided to case managers. The Recovery Mall has an established schedule of classes for clients, and all Winds of Change clients are welcome and encouraged to attend, although participation is not mandatory. Some classes offered for January 2015 are:

Assertiveness

Budgeting

Art groups

Bus riding

Wellness

Socialization

Illness Management and Recovery

Case managers advocate for quality housing for clients. One case manager interviewed was assisting his client in obtaining housing after the client was evicted. He is coaching his client regarding appropriate behavior in order to maintain housing. He is working with the client to improve his assertiveness skills and encouraging him to set boundaries with his friends who are jeopardizing his housing. The crisis line number for Winds of Change clients is visible on all the communication boards in all the Winds of Change facilities. Winds of Change maintains its own crisis line for its clients and does make necessary referrals for individuals not receiving services at Winds of Change. They communicate with the Crisis Response Therapists from Western Montana Mental Health Center as well as the Emergency Room at Saint Patrick’s Hospital if hospitalization is imminent.

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Evidence based practices are utilized according to Kay Jennings, APRN. Holistic health practices are emphasized including diet and exercise along with personal accountability for wellness. They have utilized a grant for wellness to expand lab protocols regarding risk factors such as metabolic syndrome, pre-diabetes and underlying thyroid disorders. Aleph and Winds of Change staff provide clients curriculum regarding health issues, cooking with food stamps and smoking cessation. They encourage individualized exercise programs. A treadmill along with other exercise equipment is available in the Recovery Mall. A prescription for wellness is written for clients on an individual basis once they have met with a practitioner. Individualized treatment goals include at least one wellness goal. Clients in the group homes follow the Mediterranean diet and choose recipes that follow the Mediterranean diet. Medication management is primarily handled for the majority of clients by Aleph, a separate agency within the same building housing Winds of Change. Aleph was founded by Kay Jennings, APRN. There are three nurse practitioners, two of whom have a background as adult nurse practitioners and one with a psychiatric certification as well. A psychiatrist has been appointed medical director for Winds of Change. The staff at Aleph interacts daily with the staff at Winds of Change within formal meetings and in “hallway consultations.” Case managers accompany clients to appointments if the client agrees to the arrangement. Release of Information forms need to be signed for both Aleph and Winds of Change if information is to be shared. Records of medication appointments and psychiatric evaluations are not automatically placed in Winds of Change charts even with signed release of information forms. However labs done at Aleph and quarterly medication lists are placed in the chart with release forms in place. There are two separate computer systems for the two agencies. One of the adult nurse practitioners does all the physical evaluations for the group home residents. Aleph staff is available for new patients within 24 hours during the week and there are slots daily available for crisis appointments. The medical director, Dr. Andy Sands is certified to provide suboxone treatment. Psychiatric providers meet in a formal setting with Winds of Change staff at least monthly. Case managers have the capacity to do med prompts daily if needed. Medical Administration Records in the group homes are reviewed routinely by Aleph staff. Bubble packs for medications at the group home are filled by a pharmacy. Group home staff will remind clients of medication times and availability of PRNs. Clients physically handle their own medication with staff observing. Information regarding medication is available from the pharmacist. The psychiatrist at Aleph stated he does not utilize hand-outs regarding medications. Education regarding medications and side effects are reviewed with staff and patients in educational sessions and on a 1:1 basis. Overall health and well-being as well as symptom management are highly valued goals at Winds of Change. Aleph staff routinely reviews each other’s charts to decrease poly-pharmacy. They are especially concerned with minimizing more than one antipsychotic. Clients are able to change

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prescribers upon request. Wind of Change does accept clients whose prescriber are community based but staff acknowledge accessing information can be difficult. Aleph staff is able to access the state drug registry to determine if clients are accessing emergency rooms or multiple physicians in order to procure narcotics or benzodiazepines. Client choice is a theme throughout Winds of Change and lack of compliance with current medications does not impede staff from continuing to provide services. Clients have regularly scheduled appointments with Aleph providers. The one chart reviewed from Winds of Change does address allergies in the intake evaluation. Medication errors in the group homes are documented, reviewed and assessed in Quality Assurance meetings. Trends are identified and changes made accordingly. Further criteria regarding medication management were not reviewed due to Aleph’s status as a separate entity. Aleph staff does have access to sample medications and staff reports no difficulties with the state paying for new brand medications. When the client is transferring to another provider, information is shared provided the client signs release forms for both Winds of Change and Aleph.

Access and Entry Clients have options regarding primary care providers (PCP). They can see a PCP in the community or at Aleph. Experienced staff is always available during Winds of Change business hours. Several staff commented on the availability of supervisors Stacy Wheeler, Justina Hagen and Kay Jennings, APRN. A case manager or therapist is assigned to each Winds of Change client and there is an option to have both if appropriate need is present. Winds of Change seems to be a fairly well-kept secret in Western Montana. The relatively small number of clients is a strength of Winds of Change, allowing the case manager client load to be approximately one case manager per 16 to 18 clients. This helps insure more personalized and available case management services to clients

Continuity of Services through Transitions

Winds of Change provides exceptional care and continuity of services with regard to three major client life transitions. In talking with Winds of Change staff, it seems that there is first-rate entry support, continuity, and programming for people coming into Winds of Change, including from Montana State Hospital, as well as exit support, continuity, and programming for people leaving Winds of Change residential facilities to live independently. J’s Place and Casa Dos, two Winds of Change group homes, make excellent use of the group homes’ level system to ensure that new residents have an initial very high level of support and care. The group home La Casa, which primarily houses people who are able to maintain at the highest level of the group home level system, prepares well its residents for independent living. Living in a group home does entail accepting responsibilities such as house-keeping tasks and cooking for the group.

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A third major transition is late adolescence into young adulthood. Winds of Change is starting a Transition Age Program. (TAPs), which will assist people with mental illness ages 18 to 25 achieve goals in wellness, education, and employment and also learn independent living skills, such as budgeting and cooking. This program has a capable and enthusiastic Winds of Change case manager, Paul Buckles, assigned to it full-time, and the program shows great promise.

Service Area Review Recovery Mall / Wellness Coaching The Recovery Mall is a large and very open area that gives individuals the opportunity to socialize with other individuals, exercise, work on art projects, participate in skill-building activities, and many other activities. The Recovery Mall displays a bright and inviting environment when you walk in. The room has multiple motivational posters, clients’ personal artwork is displayed, and exercise equipment and posters on how to exercise are posted around the room. Chairs and couches make it a more comfortable setting. There are classroom spaces available for different activities. The Recovery Mall typically has something going on from 10 am – 4 pm every day, with weekends having “community outings” scheduled. There are also numerous posters, bulletins, and brochures available in the hallway outside the Recovery Mall, as well as in the Recovery Mall itself. Winds of Change encourages all clients to participate in some type of physical activity, including walking, stretching, doing minimal amounts of exercises using the various equipment they have available to them, and working in programs to get “bulked up”. The Wellness Coach and upper management make it a high priority to make wellness a daily activity for clients. Traditional Age Program (TAPs) TAPs is a program focusing on the age group between 18 and 25, assisting clients who are dealing with mental health issues during the transition into young adulthood. The program currently has approximately 17 clients. The case manager running the program states that number will continue to go up as the word gets out about this program. The case manager for this program seems proactive and dedicated, stating he has seen the effects of individuals with mental issues, especially in this age group, and believes there is a great need for this type of program. Clients who are accepted into the TAPs program have all the same services/programs available to them, as any other client using the Winds of Change Mental Health Center. Winds of Change Group Homes The Winds of Change manages three group homes; J’s Place, La Casa, and Casa Dos. Each resident has a private room. All the houses accommodate both men and women. The group homes provide healthy, nutritious meals as part of their wellness/recovery program. The group home residents are brought to the Recovery Mall every day, and remain there for two hours with each visit. Residents eat their meals at the group home. The group homes use a level system that provides more support for newly admitted residents, and residents who are struggling. The houses are clean and the group home staff seem enthusiastic and dedicated to providing quality services to the residents. Staff seems to interact with residents throughout

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the day in a variety of activities, including menu planning. Interviewed residents expressed satisfaction with the group homes. Greater consideration must be given to the group home J’s Place which is in enormous need of both attention and renovation. J’s Place has a bathroom that was presented to the Board of Visitors as disability accessible; however, it appears that this bathroom is not up to current disability access architectural code. There is much discussion at Winds of Change regarding a fourth group home, to be acquired either through purchase or new construction. Rosie Jennings, the Winds of Change Group Home Manager / Vice-President of Operations, thinks that this new group home might be built on the same site with La Casa and Casa Dos.

Suggestions: 1. The treatment plans seemed hard to read, and it was hard to identify different parts of

the plan; indicate “goals”, “objectives”, etc. in bold print or in some way that these are easier to locate on the plan.

2. Have laptops for case managers, for better flexibility to work on their caseload not just at the office, but elsewhere, for example, when they are going from appointment to appointment.

3. Expand the art program and possibly having an art gallery area to display the individual’s art.

4. Increase Community Based Psychiatric and Rehabilitation Services (CBPRS) staff vehicle monthly mileage allowance.

5. Acquire a second van for transportation of clients by case managers and CBPRS staff.

Recommendations: 1) Incorporate culturally relevant activities and therapeutic goals into individual treatment

plans for clients who identify themselves as persons with a distinct cultural background. Utilize minority staff within the organization to provide training regarding the minority experience.

2) Continually consider ways to reconnect clients with family members as clients proceed further toward their recovery. Develop a procedure that encourages case managers to regularly discuss family/guardian involvement as part of the recovery process.

3) Provide more extensive Trauma-Informed Care training to staff through “live” training that includes role-play, effects of trauma, education, etc.

4) Prominently post advocacy information (Board of Visitors, Mental Health Ombudsman, and Disability Rights Montana) in all Winds of Change facilities.